Prostatitis - symptoms and treatment

What is prostatitis? We will analyze the reasons for the appearance, diagnosis and methods of treatment in the article of a doctor, urologist with 28 years of experience.

Definition of the disease. Causes of the disease

ProstatitisIt is an inflammatory process of the prostate tissue, accompanied by pain in the lower back, perineum or pelvic area, as well as disorders of the lower urinary tract.

The prostate gland (prostate) refers to the male reproductive system. It sits in front of the rectum, under the bladder and surrounds the urethra (urethra). Therefore, when the prostate gland becomes inflamed, it compresses the urethra, which further leads to various problems with urination. The main function of the prostate is to produce a secretion (fluid) that is part of the sperm and liquefies it to ensure normal sperm motility.

Pathological conditions of the prostate gland, such as cancer or benign hyperplasia, are more common in older patients. Prostatitis differs in that it affects men of all ages, but the disease is most common in men of reproductive age (8 to 35% of cases).

Prostatitis is most common in the practice of a urologist. It can occur suddenly (acute) or gradually, and its manifestations are permanent and long-term (chronic). The chronic form is much more common than the acute one. Chronic prostatitis ranks fifth among the twenty major urological diagnoses.

Prostatitis can be an independent disease or combined with benign prostatic hyperplasia and prostate cancer. In recent years, there has been a decrease in the incidence of prostatitis in the male population: if in 2012 the incidence was 275 per 100 thousand of the population, then in 2017 the primary incidence was 203 per 100 thousand of the population.

The reasons for the development of prostatitisare bacterial (infectious) and nonbacterial (non-infectious).Infectious prostatitismost common in men under 35 years of age. Most often this form of the disease is caused by gram-negative microorganisms, especially enterobacter, E. coli, dentition, pseudomonad and proteus, as well as sexually transmitted infections such as gonococci, chlamydia and others. Very rarely, prostatitis can occur due to Mycobacterium tuberculosis. In chronic bacterial prostatitis, the spectrum of pathogens is wider and may include atypical pathogens. It should be remembered that chronic bacterial prostatitis is a polyetiological disease, that is, there can be several causes.

Factors contributing to the development of inflammationin the prostate gland:

• sexually transmitted infections;
• immune deficiency states;
• prostate biopsy;
• invasive manipulations and operations;
• Lifestyle;
• diarrhea, constipation;
• homosexual contacts;
• frequent change of sexual partners;
• sedentary lifestyle, etc.

Chronic nonbacterial prostatitisdiagnosed in patients who complain of chronic prostate pain until an infectious (bacterial) cause of the disease is found in them. Despite numerous studies, the cause of this type of chronic prostatitis is not fully understood, but there are some factors that can cause its development:

• increased prostate pressure;
• muscle pain in the pelvic area;
• emotional disorders;
• Autoimmune disorders (antibodies that have to fight the infection, sometimes for some reason attack the cells of the prostate gland);
• physical activity;
• irregular sex life;
• weight lifting, etc.

In some cases, prostatitis may occur after transurethral procedures such as urethral catheterization or cystoscopy, as well as after a tranrectal prostate biopsy.

Although the true incidence of different types of prostatitis has not been definitively established, the following data are provided:

• acute bacterial prostatitis accounts for approximately 5-10% of all cases of prostatitis;
• chronic bacterial prostatitis - 6-10%;
• chronic nonbacterial prostatitis - 80-90%;
• prostatitis, including prostatodynia (neurovegetative disorders of the prostate gland) - 20-30%.

If you find such symptoms, consult your doctor. Do not self-medicate - it is dangerous for your health!

Symptoms of prostatitis

All forms of inflammationthe prostate gland, in addition to the asymptomatic, is united by the presence of the following symptoms:

• lumbar pain;
• feeling of discomfort with intestinal peristalsis;
• pain in the perineum or pelvic area;
• disorders of the lower urinary tract.

The main symptoms of the lower urinary tract in the presence of prostatitis:

• frequent urge to urinate;
• difficulty urinating, ie low flow and need for "tension";
• burning pain or its intensification when urinating.

In men with a diagnosisacute bacterial prostatitisPelvic pain and urinary tract symptoms such as increased urination and urinary retention occur. This can lead to the development of systemic manifestations such as fever, chills, nausea, vomiting and malaise. Acute bacterial prostatitis is characterized by a sudden onset of the disease with a clear clinical picture. This is a serious disease.

Men with a diagnosischronic bacterial prostatitisnotice symptoms of a periodic nature that increase and decrease. In exacerbation, pain and discomfort are noted. The pain is localized mostly at the base of the penis, around or above the anus. Also, the pain can appear just above the pubic bone or in the lower back, spreading to the penis and testicles. Defecation also becomes painful. Occasionally there are signs of infection of the lower urinary tract: burning pain and frequent urination, frequent urges. These symptoms can be confused with the manifestations of acute bacterial prostatitis, but usually there is a sudden onset, chills, fever, weakness, pain throughout the body, lower back and genitals, frequent and painful urination, pain with ejaculation. If you find such symptoms, you should consult a doctor immediately.

If the standard modern examination has not established that chronic pain is caused by a pathological process in the prostate gland, then we are dealing with chronic nonbacterial prostatitis, which is also calledchronic pelvic pain syndrome(the term has been used since 2003). In the presence of chronic pelvic pain syndrome, a man's quality of life is significantly reduced, as this syndrome sometimes leads to various psychological and sexual disorders:

• increased fatigue;
• feeling helpless;
• erectile dysfunction;
• painful ejaculation;
• pain after intercourse, etc.

In chronic nonbacterial prostatitis / chronic pelvic pain syndrome, there is a feeling of constant discomfort or pain in the lower back, more often at the base of the penis and around the anus, for at least 3 months. Painful sensations are localized in one "target organ" or several pelvic organs. Most often in this form of prostatitis the pain is localized in the prostate gland (46%).

In chronic prostatitis, sexual disorders have a number of characteristics. First, all components of a man's copulatory (sexual) function are impaired to varying degrees: libido, erection, ejaculation. Second, sexual dysfunction occurs mainly in individuals with a long (more than 5 years) history of the disease. Third, sexual dysfunction is often the main reason for seeking medical help.

Erectile dysfunction is noted by 30% of patients suffering from chronic prostatitis, largely due to the psychogenic factor - catastrophic perception of the disease.

Symptoms of prostatitis appear at least once in a lifetime in 50% of men.

Pathogenesis of prostatitis

The mechanism of development of prostatitis is multifaceted and very complex. Many factors are involved in its development. Most cases of acute bacterial prostatitis are caused by a cascade of processes caused by ascending urethral infection or intraprostatic reflux (backflow of urine).

The penetration of microorganisms into the prostate gland is possible ascending (through the urethra) or transrectally via the lymphatic system. Diarrhea and constipation associated with impaired rectal barrier function are considered to be a provoking factor in chronic prostatitis. However, the mechanism of penetration of microorganisms into the prostate has not yet been clearly established.

Urinary disorders with prostatitis can be the result of:

• increasing the tone of the smooth muscles of the prostate urethra by increasing the activity of adrenergic receptors;
• enlargement of the prostate or narrowing of the urethra, leading to rapid urine flow, obstruction of the bladder outlet, and intraprostatic reflux.

In the future there is a violation of the drainage of the ducts of the prostate gland, stagnation of prostate secretion, edema, activation of the arachidonic acid cascade, inflammation and ischemia. A vicious circle of pathological changes is forming.

Classification and stages of development of prostatitis

There are 4 main categories (types) of prostatitis.

1. Acute bacterial prostatitis(category I).
2. Chronic bacterial prostatitis(category II).
3. Chronic nonbacterial prostatitis / syndromechronic pelvic pain (category III). It can be inflammatory (category III A) or non-inflammatory (category III B).
4. Asymptomatic inflammatory prostatitis.Histological prostatitis identified by prostate biopsy (category IV).

Chronic bacterial prostatitisUnlikespicy,manifests as recurrent episodes of exacerbation with or without complete remissions between them. The symptoms are usually less severe than in acute prostatitis.

Classification of the National American Institutes of Health. . .

• Type I(acute bacterial prostatitis) - an acute infection of the prostate gland: the symptoms of the disease appear suddenly. Chills, fever, pain throughout the body, weakness, low back and genital pain, frequent, painful urination, pain during ejaculation. Potential symptoms of acute bacterial prostatitis include blood in the urine and / or semen. This is rare. It is effectively treated with antibiotics.
• Type II(chronic bacterial prostatitis) - chronic or recurrent infection of the prostate gland: the symptoms are the same as in acute prostatitis, but appear gradually and are less pronounced. Several courses of antibiotic therapy may be needed.
• Type III(chronic nonbacterial prostatitis and chronic pelvic pain syndrome): no evidence of infection.
• III A type: presence of leukocytes in the ejaculate / prostate secretion / third portion of urine obtained after prostate massage.
• III In type: lack of leukocytes in the ejaculate / prostate secretion / third portion of urine obtained after prostate massage. Low back and genital pain, frequent urge to urinate, difficulty urinating (often at night), burning or painful urination and ejaculation. It accounts for about 90% of all cases of prostatitis. There are no known causes or clinically proven treatment.
• Type IV(asymptomatic inflammatory prostatitis): Sometimes an increased number of white blood cells. No treatment is required. It is found in a prostate biopsy.

The boundaries between the various forms of prostatitis are blurred.

Complications of prostatitis

In inflammatory lesions of the prostate gland, nearby organs are involved in the pathological process: seminal tubercle, Cooper's glands, seminal vesicles and posterior urethra. The infection can penetrate both the prostate gland and the surrounding organs.

Vesiculitis- inflammation of the seminal vesicles. The pain is localized in the groin area and deep in the pelvis, radiating to the sacrum. The pain is usually unilateral, as both seminal vesicles are affected to varying degrees. Vesiculitis may be asymptomatic. The only complaint patients may have is the presence of blood in the semen. Periodic pyuria (pus in the urine) and pyospermia (pus in the ejaculate) are also noted.

Posterior urethritis, coliculitis (inflammation of the seminal tubercle). . . In prostatitis, the infection penetrates the seminal tubercle, this is due to the proximity of the prostate gland to the secretory ducts.

Prostate abscess.Pathogens that cause prostatitis can also provoke a prostate abscess. It is a severe septic (bacterial) disease that is accompanied by weakness, fever, chills with sweating. In some cases, impaired consciousness and delirium are observed. The patient needs hospitalization.

Prostate sclerosis (fibrosis).This is a late complication of prostatitis, which is based on the replacement of prostate tissue with scars (connective tissue degeneration, ie sclerosis), which leads to the fact that the gland shrinks, shrinks in size and completely loses its function. As a rule, sclerotic symptoms develop long after the onset of the inflammatory process in the prostate gland.

Prostate cysts.These formations can contribute to the formation of stones in the prostate gland. The presence of an infection in the cyst can lead to a prostate abscess. It is not difficult to diagnose a prostate cyst with the help of ultrasound. They can also be detected by digital rectal examination.

Prostate stones.They are quite common. The causes of the disease are not fully understood, but most experts are unanimous that they occur as a result of a prolonged inflammatory process in the prostate gland. The stones are single and multiple, with a diameter of 1 to 4 mm. Large stones are rare. The stones clog the gland, causing the secretion to stagnate in it, the gland is overstretched and separate cysts form, into which the infection penetrates. Patients with prostate stones have to deal with constant dull pain in the perineum. The painful sensations spread to the glans penis and cause frequent urges to urinate, which becomes difficult and painful.

Infertility.Chronic long-term prostatitis mainly reduces the motor function of sperm, which makes them completely immobile. One of the consequences is a violation of their production, the formation of immature sperm, which have an unusually altered shape (and a smaller number of them than before).

Ejaculation disorder.Prostatitis of all forms causes sexual dysfunction. At first, patients face premature ejaculation with a normal erection, which then weakens and the rate of orgasm decreases. The prolonged existence of chronic prostatitis contributes to a decrease in the production of male sex hormones and a weakening of libido.

Erectile dysfunction.The relationship between chronic prostatitis / chronic pelvic pain syndrome and erectile dysfunction has been described. This disorder is especially painful for men.

Diagnosis of prostatitis

The appearance of the first signs of inflammation of the prostate gland requires immediate medical attention. The urologist will rule out many diseases that have similar manifestations and will determine to which category (type) the disease belongs. Before choosing a treatment, the specialist will perform the necessary examinations and offer to undergo an evaluation test.

What questions can the doctor ask

At the appointment, the doctor will definitely specify: the duration of the clinical manifestations of the disease, the location and nature of the pain, for example in the perineum, scrotum, penis and inner thigh; changes in the nature of semen (presence of pus and blood).

At the reception the urologist will offer to fill out special questionnaires, one of which is the index of symptoms of chronic prostatitis.

The patient should ask the doctor questionsabout what tests and research will need to be done, how to prepare for them, what treatment he plans to prescribe and where I can get more information about the disease.

Chronic bacterial prostatitis is diagnosed when symptoms persist for at least three months.

The study will include:

• Digital rectal examination of the gland to determine the degree of enlargement of the prostate and its consistency.

• Tests for secretions of the prostate, urine and / or ejaculate.
• Identification of urogenital infection.
• Ultrasound examination of the urinary system (kidneys, prostate, bladder with determination of residual urine).

• Urodynamic examination.

In the case of acute bacterial prostatitis, a swollen and painful prostate gland can be detected by digital rectal examination. Prostate massage is contraindicated as it can lead to bacteremia and sepsis.

The most important study in the study of patients with acute bacterial prostatitis is the culture of prostate secretion. To categorize chronic prostatitis, quantitative culture and microscopy of urine samples and prostate secretions obtained after prostate massage are still important methods.

Androflor - a comprehensive study of the microbiocenosis of the urogenital tract in men by PCR. Allows you to determine the qualitative and quantitative composition of the microflora. It is used for diagnosis and control of the treatment of inflammatory infectious diseases of the genitourinary system.

After determining the cause of the disease, the doctor will recommend a course of treatment. It should be remembered that standard methods in only 5-10% of cases can detect an infection, which ultimately leads to prostatitis.

What is the relationship between prostatitis, prostate specific antigen (PSA) and prostate cancer

Measurement of total PSA and free PSA levels in prostatitis does not provide additional diagnostic information. It is known that in 60 and 20% of patients with acute and chronic bacterial prostatitis, the level of prostate-specific antigen (PSA) increases, respectively. At the end of treatment, PSA levels decreased in 40% of patients. PSA is not considered a specific marker for prostate cancer, as PSA levels may be elevated in benign prostatic hyperplasia and prostatitis.

Treatment of prostatitis

The leading role in the treatment of pathology is assigned to drug therapy.

Treatment with alpha1-blockers

Alpha1-blockers are prescribed to patients who complain of difficulty urinating. These drugs help relieve urination and relax the muscles of the prostate gland and bladder. Some patients are prescribed medications to lower hormone levels, which can help shrink the gland and reduce discomfort. Muscle relaxants can help relieve pain caused by a swollen prostate that puts pressure on nearby muscles. Non-steroidal anti-inflammatory drugs (NSAIDs) can help if there is pain.

Standard antibiotic therapy in most cases does not reduce the number of recurrences of the disease and therefore an integrated approach is often used, which is also prescribed.auxiliary drugs: biostimulants, extracts of various plants and insects and their biological components, which may be in the formrectal suppositories. . . Despite the large arsenal of drugs, the effectiveness of their use remains insufficient.

Physiotherapy in the treatment of prostatitis

For chronic prostatitis of categories II, III A and III B can be additionally used physiotherapeutic methods:

• prostate massage (prostate);
• laser therapy;
• microwave hyperthermia and thermotherapy;
• electrical stimulation with modulated currents of skin or rectal electrodes;
• acupuncture (acupuncture).

The efficacy and safety of these treatments are still being studied. It is also used to treat prostatitisfolk methods, e. g.hirudotherapy.The effectiveness and safety of this method of treating prostatitis has not been proven.

Stem cell injection

Cell therapy (stem cell injections) in the treatment of prostatitis is currently a promising technique in the early stages of development. Currently, with regard to the injection of stem cells into the prostate, we can only have hypotheses about its mechanisms, as well as empirical data obtained from individual groups of researchers.

Surgical treatment of prostatitis

Surgical methods are used only to treat complications of prostatitis - abscess and suppuration of seminal vesicles.

Treatment of chronic pelvic pain syndrome requires separate consideration. Asymptomatic inflammatory prostatitis (category IV) should not be treated unless the patient is planning prostate surgery. In this case, the patient is given a prophylactic course of antibiotic therapy.

Diet and lifestyle in prostatitis

No special diet is required for prostatitis, but eating lots of vegetables, lean meats and dairy products will improve bowel function. It is important to consume enough fiber, foods rich in vitamin E (wheat germ, corn oil, etc. ), sugar should be replaced with natural honey. Proper nutrition in prostatitis can improve bowel function and reduce the likelihood of recurrence or speed recovery. It is advisable to stick to a healthy lifestyle, drink more fluids and limit caffeine and alcohol.

Forecast. Prevention

Acute prostatitis often becomes chronic, even with timely and adequate treatment.

Full recovery is not always possible, but with proper sequential therapy and following the doctor's recommendations, it is possible to eliminate the discomfort and pain. Independenthome treatment of prostatitiscan be dangerous and lead to complications.

Not all cases of prostatitis can be identified as a cause, but there are a number of steps you can take to try to prevent prostatitis. The same steps can help control existing symptoms:

1. Drink plenty of fluids. Drinking a lot of fluids leads to frequent urination, thus facilitating the flushing of infectious agents from the prostate urethra.
2. Empty your bladder regularly.
3. Avoid irritating the urethra. Limit your intake of caffeine, spicy foods and alcohol.
4. Reduce the pressure on the prostate. Men who ride a bike often need to use a split seat to relieve pressure on the prostate area.
5. Stay sexually active.